Job Abstract

• Collaborates with Case Managers and Social Workers in baseline patient assessment to identify post hospital support and any discharge needs.

• Collaborates with Case Managers and Social Workers jointly to communicate and problem solve in the development of the TOC plan including offering choices and preferences for post-acute providers, available resources and sharing the expected discharge date and disposition.

• Ensures the patient and medical facility receives information on benefit coverage including partnering with payers when needed.

• Monitors progress towards meeting the TOC goals and escalates to Case Managers and Social Workers any barriers to achieving the recommended goals identified in the plan.

• Assures the patient and medical facility are kept informed of the progression of the TOC plan throughout the hospital stay.

• Coordinates all the necessary post discharge referrals and authorizations in collaboration with the CC team.

• Experienced
• 2 years